Commentary by David Henderson Slater, M.D., Consultant in Neurological Disability and Rehabilitation Medicine, The Oxford Centre for Enablement, Oxford, England; and Laura May and Dora Steel, Class of 2010, University of Oxford Division of Medical Sciences
A faculty perspective: Why should medical students study literature, film, and the visual arts?
Why should doctors know about the arts? Is it just to have a rewarding interest away from a busy professional life? Or is it simply part of being a rounded personality, to be able to engage in enlightened conversation at a dinner party? Although there is a long tradition of doctors who have a ’second career’ as artists, (Chekhov and Keats are obvious examples), in Britain medical training has become very scientifically driven. Medicine here is usually an undergraduate degree, often with an intermediate year of science leading to an additional Bachelors degree before qualification after a further three years. Few medical students have previously studied an arts subject to degree level (I had, but that is relatively rare). So most newly qualified doctors have had a very scientifically oriented training.
In the last few years in the UK there has been an increasing awareness of the value of the arts as a part of the formation of a rounded doctor. In some ways this represents a return to traditional values. Most entrants to medical school were traditionally from privileged sections of society, privately educated; a ’rounded’ student with a broad education, along the lines of the Corinthian ideal, could have been assumed. That has been less true in the last twenty or thirty years. And it has been observed that this lack of a sense of values and interpretations beyond the purely scientific is to the detriment of Medicine and its practitioners. As a consequence there has been increasing interest in making the undergraduate medical curriculum broader than a purely scientific training in Medicine. Whereas the old medical syllabus was tightly controlled and restricted, we now have optional modules as part of the undergraduate degree; these are known in Oxford as Special Study Modules. These last from four to six weeks. Students here choose them in their fourth and sixth year of study.
I work as a specialist doctor in a centre for people with life-long disabling conditions - at the Oxford Centre for Enablement (OCE), which is part of the Nuffield Orthopaedic Centre, one of the Oxford teaching hospitals. We have close links with both the University of Oxford and Oxford Brookes University. Our patients in OCE have a wide variety of chronic neurological conditions such as multiple sclerosis, motor neuron disease, stroke and brain injury, or have experienced major physical trauma resulting in amputation; they are often very immobile, and have a variety of cognitive impairments, emotional problems, pain, spasticity etcetera. We cover a large area of central southern England as a specialist tertiary referral centre. I run a Special Study Module for medical students from Oxford University who are in their fourth year of training (the course most of them follow in Oxford is six years long). The module (‘Models and Meanings’) attempts to combine study of the disabling conditions and the person’s experience of them with a study of the representation of illness and disability in the arts.
When we see a patient in clinic, or in the operating theatre, or on the ward, we see only a tiny part of their lives. We tend to see what they want to present to us. The clinic and the ward are not real life, or only a tiny part of it. If I really want to know what life is like for my patient I have to spend hours at it - perhaps also visiting them at home (something I often do) or in the Nursing Home. That way I get a feel for the things that get forgotten in clinic- such as the long hours of inactivity, or the financial poverty of the family, and an appreciation of what is important to them - for example the religious artefacts on the walls, the family pets, the old cars littering their garden, the half finished Do-it-Yourself projects. I had a young patient who was wheelchair -bound, and his grandfather was trying to make a shower room for him.A But the room never got finished - it filled up with the plumbing tools, and the debris of the family’s life, and he was left to fend for himself in increasing chaos. Seeing him in his room, cold and isolated, in a wheelchair most of the day, with no easy access to a bathroom, alone in the house for hours, taught me more about his life than any number of clinic appointments.
But sometimes we can’t access the patient in this direct way, and sometimes we don’t notice things. Our minds and our eyes need to be trained to spot things; so does our imagination. As trainee doctors we get extensive training in physical examination. I believe we also need to train our imagination, to learn to think what life is like for others, to experience things vicariously. When I was a medical student, I had never experienced a major bereavement. I read a book by C. S. Lewis, A Grief Observed, and I felt something of his grief, far more than from anything else I had experienced up to that point in my life. Literature and films can expose us to things we cannot otherwise experience.
However, what we see and read may be misleading. All art is selective from reality, and represents reality with a particular slant. In Britain, many people above the age of 50 will have a clear idea of what they think life as an amputee is like which is based on a film about a Second World War fighter pilot, Douglas Bader, whose exploits impressed the nation, led to his being knighted, and set a standard of achievement which is hard for real life amputees to match. Similarly the achievements of Para-Olympians and wheelchair athletes have set a standard infinitely beyond the hopes of most people suffering from significant impairments. The images on the TV screen show us the amputee who gets around the course, and are very unlikely also to show us the blistered stump, or the half-way-round drop out.
In the Special Study module for Oxford University medical students, I am encouraging students to think about representation, about the way we see things as doctors, the things we tend to notice, to comment upon (the thin abdomen, the scarring on the back of the leg), and perhaps also the things we tend to ignore or not notice - the red eyes of the patient’s wife sitting in the waiting room, the bewildered children playing with the clinic’s toys. We are trying to notice the ways in which disability and illness tend to be represented in the media (the ‘Plucky Fighter’, for example). We are trying to compare experience and representation - one of the current students is looking at the experience of amputees and comparing it with the representation of amputation in films, seeing what the patients themselves think about the way they are represented. In the last few days we have looked at a film which will be familiar to many because of its portrayal of the lives of a community of deaf students and their various hearing teachers. Children of a Lesser God has continued to cause controversy amongst non-hearing viewers over the years. Below are the observations of two medical students.
A medical student perspective: Disability and Children of a Lesser God
As medical students, we do get some teaching on disability as part of our training, but it is limited and always seen within the context of medical care rather than as a topic in its own right. The only window we have into most of our patients' lives is the time they spend in hospital, and it's easy to forget that many disabilities can have an impact on everything an individual does, not just their use of healthcare. As part of our training we are allowed to spend some time exploring subjects that particularly interest us, so we have taken the opportunity in this module to combine thinking about portrayal of disabilities in the arts with actually meeting people undergoing therapy at the Oxford Centre for Enablement. We watched Children of a Lesser God as part of an introduction to issues surrounding deafness, but also more generally to the problems that can arise in interactions between disabled and able-bodied people.
The film is set in the 1970s, when educational segregation based on disability was more common than today. Most of the action takes place in an isolated boarding school for deaf children on a remote island, and although the school is presented as a supportive and stimulating environment in which to learn, the expectations of the Headmaster for his pupils are limited - he seems entirely satisfied that Sarah, his star pupil, remains working on the island as a cleaner. Perhaps as a result, she is frightened by life outside the school community, which she has not experienced since childhood. This highlights the central dilemma of education for people with disabilities such as deafness: segregation within a supportive and specialised community, or integration into the wider world?
In Children of a Lesser God, segregation between 'hearing' and 'non-hearing' people is not just limited to the educational years. As exemplified by the adult lives of Sarah and Mr Leeds, deafness seems to divide the world into two opposite halves: those who can hear, and those who can't. This is portrayed as a sharp and definite distinction: perpetuated from outside the deaf community, as society segregates deaf from hearing; and from within it, as deaf characters such as Sarah and the children refer to 'hearing boys' or 'hearing girls.' Perhaps because it is drawn as such a sharp distinction, the interface between these two worlds becomes fraught with misunderstanding and assumptions, and this is exemplified in the romantic relationship between Sarah and Mr Leeds. Only at the end of the film, and after much hurt on both sides, is a point of compromise found. To what extent an impairment forms part of both an individual and a collective identity is an interesting question. It is a question complicated by the fact that one impairment is not equivalent to another, and that Deaf people may have a stronger sense of collective identity than, for example, people who have had amputations.
In describing these two communities, the film doesn't explicitly use loaded terms such as 'normal' and 'abnormal', but we perceive that on some level assumptions about what is normal and what is not are reflected in the behaviour of the key characters. Mr Leeds, young and handsome, arrives on the scene as something of a 'knight in shining armour', determined to improve the prospects of his pupils by teaching them to speak, rather than to sign. Although he is a flawed character, it is easy to identify with his enthusiastic altruism to 'help', particularly as doctors. Perhaps this is something we should be wary of; and find out what sort of interaction a patient may want with the healthcare profession before we try to 'get them back to normal.' Sarah's fierce opposition to Mr Leeds's attempts to teach her how to speak in the film are perhaps an extreme example of this, but it highlights the dangers of assuming too much, even with the best motives.
Ill-considered terminology, however, is far from the greatest threat which has historically faced disabled people from their able-bodied peers. The exploitation of disabled people is a familiar theme in the arts, and one which Children of a Lesser God explores: Sarah has been sexually exploited by her sister's hearing friends. Some disability activists criticise depictions of disabled people as victims, but sadly the frequency of such depictions probably reflects a reality in which abuse and neglect are common. Interestingly, this film also explores "exploitation" in another sense: Sarah exploits her deafness as a protection from the outside world. She is often demanding and gets away with more than a hearing woman would be able to, partly through using her deafness as a defence and as an excuse for unreasonable behaviour. There is ample explanation and excuse for this in her abusive background, but the point that disability may not be only a vulnerability but also a tool in social interaction remains.
Although the film explores many aspects of life as a deaf person and interactions between deaf and hearing people, one thing it struggles - understandably - to represent is the actual experience of deafness. It is as full as any other film of sound, music as well as dialogue - which, incidentally, is nearly always spoken as well as signed. Only in the swimming pool scenes, first when Sarah swims alone and later when Mr Leeds joins her under water, does the viewer experience complete silence. This is a remarkably effective device, and one that perhaps the film makers might have exploited more fully.
This commentary discusses Children of a Lesser God as a film about deafness, but that is far from all it is. First and foremost, it is a love-story, and also a story about coming of age and learning to see the world in a new way. Deafness is a central, but not the only, theme, and to treat a complex human story as a tract on deafness would be a reductive and limited view. Even if it were, it would be misguided to generalise from this film about disability in general; firstly, because not all disabilities are the same, and secondly because for many, deafness is not a disability at all.
ACharacteristics of the patient described have been changed to prevent identification.